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2. 
3. CityLink Paratransit Service Application

   Please use this application if you are a medical professional verifying the eligibility of a potential client.

    

   The following application must be completed by a medical professional (doctor, nurse, licensed therapist, social worker, or O&M specialist).

    

   The individual who has asked you to review and sign this application is applying for CityLink Para-transit Services. ADA para-transit service is intended ONLY for those trips that the person cannot take on the regular public bus system due to his/her disability. Please complete the assessment below. DO NOT USE ABBREVIATIONS OR CODES.

    

   You may e-mail any questions to citylink@abilenetx.gov or call 325-676-6287

5. Professional Verification Assessments
7. Patient Last Name*
8. Patient First Name*
12. What is the nature of the disability or condition that affects the person’s ability to use the regular fixed route bus system?
    (check all that apply)
14. General Medical Conditions*

    1. None
    2. Cancer
    3. Kidney Failure

    1. Respiratory
    2. HIV/AIDS

    1. Diabetes
    2. Other
15. If Other, please specify*
17. Bone & Joint Conditions*

    1. None
    2. Amputation
    3. Broken Bone

    1. Arthritis
    2. Osteo-Arthritis

    1. Rheumatoid Arthritis
    2. Other
18. If Other, please specify*
20. If Amputation, please specify*
21. If Broken Bone, please specify*
23. Brain/Nerves/Muscle Conditions*

    1. None
    2. Alzheimer's/Dementia
    3. Brain Injury
    4. Cerebral Palsy

    1. Epilepsy
    2. Hemiplegia
    3. Multiple Sclerosis
    4. Muscular Dystrophy

    1. Stroke
    2. Quadriplegia
    3. Other
24. If Other, please specify*
26. Heart & Circulatory Conditions*

    1. None
    2. Angina
    3. Heart Attack

    1. Heart Surgery
    2. Edema
    3. Congestive Heart Failure

    1. Peripheral Vascular Disease
    2. High Blood Pressure
    3. Other
27. If Other, please specify*
29. Lung & Breathing Conditions*

    1. None
    2. Asthma

    1. Chronic Obstructive Pulmonary Disease (COPD)
    2. Cystic Fibrosis

    1. Lung Cancer
    2. Other
30. If Other, please specify*
32. Vision/Hearing/Speech Conditions*

    1. None
    2. Aphasia
    3. Cataracts

    1. Glaucoma
    2. Totally Blind
    3. Diabetic Retinopathy

    1. Deaf
    2. Hard of Hearing
    3. Other
33. If Other, please specify*
35. Developmental/Mental Conditions*

    1. None
    2. Autism
    3. Psychosis
    4. Mild Development Disability

    1. Moderate Development Disability
    2. Severe Development Disability
    3. Metal Retardation
    4. Other
36. If Other, please specify*
40. Is the health condition or disability temporary?*

    1. Yes
    2. No
41. If yes, how long do you expect it to last?*
43. Does the person require a personal care attendant (PCA) to accompany them on trips?*

    1. Yes
    2. No
45. Explain in detail why the applicant is not physically or mentally able to walk to the regular bus route.*
49. Name of Healthcare Professional or Agency*
51. Person Completing Verification*
52. How long have you been treating the applicant?*
54. Business Address*
55. Business Telephone*
57. Signature of Qualified Professional*
58. Date*
    Date
Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field